Excelcare at Newark: Immediate Jeopardy Violations - DE
Federal inspectors cited Excelcare at Newark LLC with Immediate Jeopardy on December 23, 2025. The citation, the most serious level of harm in the federal inspection system, was triggered by the facility's failure to assess the resident's deteriorating condition, notify her physician in time, and call for emergency medical help while she struggled to breathe and her oxygen readings stayed dangerously low.
The resident, identified in inspection records only as R1, had complained of difficulty breathing. A certified nursing assistant, identified as E7, said she had checked R1's oxygen saturation that night and found it had dropped. "It went up to 92%," E7 told inspectors. "I told her nurse, E5. It was between 3:00 and 4:00 AM. It was before my break." When a surveyor asked whether E7 had documented the vitals or the oxygen saturation reading, the answer was direct: "I did not document them."
Nothing appeared in R1's clinical record to show that a nurse had followed up with any assessment, any intervention, or any call to a medical provider.
The following day, a therapist identified as E8 told inspectors she had also noticed R1 was in distress. "I remember R1 did not do therapy that day," E8 said. "I asked why she couldn't do therapy. R1 told me she couldn't do therapy because of her breathing." E8 said she checked R1's vitals herself, documented them in her own therapy note, and walked directly to the nurse whose cart was positioned just outside R1's room. That nurse, E8 said, took R1's pulse ox again.
R1's nursing record contained none of it. No documentation of shortness of breath. No notation of the inability to participate in therapy. No record of any intervention. No record that a provider was ever contacted.
A supervisor identified as E6 told inspectors she had been called to R1's room by nurse E5 twice. The first time, R1 already had oxygen on and appeared comfortable. The second call came because R1 was having shortness of breath again. "E5 put the non-rebreather on R1," E6 said. When inspectors asked E6 what oxygen saturation level R1 was at when the mask went on, E6 said she couldn't remember. When they asked how much oxygen R1 was receiving, E6 said she couldn't remember that either. Then she added: "We did not have time to document the vitals."
A non-rebreather mask delivers the highest concentration of oxygen that can be given outside a hospital. The facility's own staff development coordinator, E13, told inspectors exactly when one should be used: "If a non-rebreather is being used, 911 should already be in route."
911 had not been called.
E13 told inspectors the nurses had been trained on oxygen therapy. The most recent in-service, she said, had covered vital signs monitoring, nursing assessment, emergency response, and the correct use of a non-rebreather mask, including that it requires 10 to 15 liters of oxygen. When inspectors asked when that training had occurred, E13 gave a date. The training had happened. The knowledge, according to E13, was there.
A separate nurse, E10, a licensed practical nurse, told inspectors something different. "We are not trained on oxygen use," E10 said. "If someone is in respiratory distress, I would put them on nasal cannula at 2 liters. If they are under 92%, I will inform the provider." E10 did not mention a non-rebreather mask. E10 did not mention calling 911.
The facility had provided inspectors with an undated internal document listing competencies the facility had identified as essential to safe care. The list included vital signs monitoring and nursing assessment, recognition and timely reporting of changes in resident condition, oxygen therapy and respiratory treatments, and emergency response and clinical escalation. The document was not dated. There was no evidence in R1's record that any of those competencies had been applied when she needed them.
Inspectors called the Immediate Jeopardy at noon on the day of the inspection. The citation documented the facility's failure on three connected points: it did not adequately assess R1's change in condition, it did not consult the medical provider in time, and it did not promptly call for emergency medical help when R1 was showing obvious signs of respiratory distress and her oxygen saturation was falling. Inspectors also found the facility failed to maintain R1's oxygen delivery at an appropriate level while waiting for emergency services that were never summoned.
The facility submitted an abatement plan that afternoon. Licensed nursing staff were re-educated on recognizing respiratory distress, conducting respiratory assessments including vital signs and oxygen saturation, initiating and monitoring oxygen therapy, and notifying providers in a timely way. All residents were screened for respiratory distress. Those identified with distress were assessed and given interventions.
The exit conference was held at 4:20 that afternoon. Present were the nursing home administrator, the director of nursing, the assistant director of nursing, and a vice president of operations.
The inspection record does not say what happened to R1 after the non-rebreather mask went on her face and no one called for an ambulance. It does not say whether she was eventually hospitalized, or when, or what her condition was when she left. It does not say whether the oxygen held, or whether it didn't.
What the record shows is a woman who told staff she could not breathe, whose saturation dropped in the early morning hours, who couldn't make it through a therapy session the next day because of her breathing, and who ended up in a non-rebreather mask while the people around her acknowledged, later, that they had not documented her vitals because they did not have time.
The facility's own training materials said that when a non-rebreather goes on, the ambulance should already be coming.
It wasn't.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Excelcare At Newark LLC from 2025-12-23 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
EXCELCARE AT NEWARK LLC in NEWARK, DE was cited for immediate jeopardy violations during a health inspection on December 23, 2025.
Federal inspectors cited Excelcare at Newark LLC with Immediate Jeopardy on December 23, 2025.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.